Jawra Devi Kasturi Devi

Sugni Devi Teji Devi

Noja Devi Shanti Devi
Badu Devi Lakshmi Devi
Sammu Devi Barju Devi
Dhapu Devi Mukhi Devi
Gawra Devi Pempa Devi
Kasini Devi Khatu Devi
Reshma Devi Hurma Devi
Ganga Devi Lali Devi
Parmi Devi Saraswati Devi
Santosh Devi
Chauthi
Devi Jani Devi Nathi Devi
Mohini Devi Kamla Devi
Shayar Devi Soni Devi Sohan Kanwar Jamuna Devi
Lakshmi Devi Gomti Devi
Maghi Devi Rami Devi
Manohari Devi
Nainu
Devi Chini Devi Kailashi Devi Khamma Devi
Gowra Devi Phooli Devi
Chunni Devi Pappu Devi
Sua Devi Jamuna Devi Nasiba Moomal Nainu Devi
Jamuna Devi Choti DeviRadha Devi Gawra Kanwar Paro Bai Dhapu Bai
Babri Bai Lichma Bai Aasu
Bai Bhuri Bai Gawara Bai
Meera Devi Jeti Bai Shiv
Bai, Badhu Bai, Samu devi

barefoot doctors
experiences from
the Thar

Urmul

barefoot doctors
experiences from
the Thar

Acknowledgements:
Pushpa Purohit, Gyanendra Srimali, Dr. Harishankar Bhojak,
Ram Prasad Harsh, Himanshu,
Arvind Ojha
Developed by
Deepika Nayyar, Ravi Mishra
Urmul Trust, Urmul Bhavan
Bikaner 334001, India
mail@urmul.org
Published by
Urmul Seemant Samiti
Bajju 334305, India
uurmulssb@gmail.com
2012

Content
Preface/1
Introduction/ 3
Who are CHW/ 5
CHWs and Urmul/ 7
Swasthya Sathin in
action/ 13
Experiences/ 21

Acronyms used in the document

ANM: Auxilliary Nurse Midwife
ASHA: Accredited Social Health Activist
CAD: Command Area Development
CHW: Community Health Worker
ICDS: Integrated Child Development Services
PHC: Primary Health Centre
SHG: Self Help Group
SMC: School Management Committee
VHSC: Village Health and Sanitation Committee

Preface
9

00,000 newborns, in India, die every

year. This means more than one child
is dying every minute! Over 350,000
mothers die due to complications during
pregnancy and childbirth. Nearly 115
million children, globally, remain undernourished and over 40 percent of these
live in India. Pneumonia and diarrhoeal
diseases are the biggest cause of death of
children under age of five. Tuberculosis
and Malaria are preventable, curable yet
are the most fatal diseases. The coverage
of crucial child-health services often remains inadequate and under-addressed.
The governments, world over, are making efforts to strengthen the core of the
society mother and child. India has an
extensive health care system and infrastructure in National Rural Health Mission and other platforms. India, however,
faces stiff issues in making an effective
last mile reach. Attributing to systemic
loopholes and the expanse of the country- this otherwise comprehensive system becomes handicapped. Moving towards the west end of the country-in
desert Rajasthan, the challenges aggra-

vate further because of the desert ecology and socio-economic demographics.

The traditional and social milieu rooted
in feudalism and patriarchy, additionally
intertwines the system fallacies
Amidst these poor and classically unique
situations of health care system and inefficient delivery, Community Health
Workers have proven to be enormously
effective in linking communities with
health services. They are a local resource
unit well-trained and most effective
in formal health service delivery at the
grassroots both in costs and in resources. CHWs being the local individuals
seamlessly integrate the first hand-curative medical service with locally contextualised awareness advice. They have
proven to be highly effective advocates
for social justice, gender equity, and education awareness.
Post the Alma Ata Conference in 1978,
states world over have been experimenting
with the concept of Community Health
Workers. Since then, CHWs have become a phenomenon in the global south

or the marginalised regions all across to

support primary health facilities. The
African and the Asian experiences, over
time, substantiate the relevance and need
of the Community Health Workers. The
developing countries, amidst their poor
economies and limited resources, strive
to improve health care infrastructure
and allocate more efficient resources to
better their healthcare services. Towards
achieving this CHWs play a vital role
in delivery at the grassroots and also in
educating their communities to take the
onus for better health.

This publication is an attempt to document the learning and experiences of

Urmul- a network of NGOs working in
over 1000 villages in Thar Desert of India- has been working with Community
Health Workers for the last 25 years. It
documents a localized and decentralized
approach of the specific intervention- designed, executed, adapted and up-scaled
starting with over 80 remotest villages in
Rajasthan. We hope the document will
be helpful for those working in similar
domains, practitioners, academia, policy
makers and community, at large.

INTRODUCTION

ndia is one of the fastest growing

economies today. The large dividend, resting in the worlds largest youth
population, is providing the nation with
the much-heightened acceleration. This
has resulted in attention to improvement
plans for healthcare systems in the recent
years in both, raising awareness and
service delivery. Recognizing the importance of health in the process of economic and social development, the National
Rural Health Mission (NRHM) has been
set up to carry out necessary architectural corrections in healthcare systems. This
aims to ensure the last mile reach and effective delivery. However like many other programmes, this is also designed in a
centralised approach. Homogenous and
largely sweeping solutions, designed in
a common everywhere design does not
effectively address the root-cause, rather
it ends up creating newer loopholes in
execution and operations. With limited
resources, poor support and inadequately
trained leadership the system ends up on
low delivery and unsustainable pathway.
The Thar Desert expands in 200,000
square kilometres and Bikaner district
covers over 27,244 square kilometres.
The climate and terrain makes it the most

inhospitable and forbidding places in the

country with temperatures reaching below freezing in winters and in excess of
48 C in summers. Rains are infrequent
and do not exceed 27 centimetres. Depending on rain and yield season, families here live moving between the village
and their Dhanis (hamlets). This makes
even basic facilities in health education
and governance difficult to, both, access
and delivers. The public infrastructure
remains very limited and mostly defunct.
The distances between villages and Dhanis make availability of appropriate medical care a logistical difficulty, especially,
in case of an emergency. Sometimes the
average travel distance to access the most
basic health service could be at a minimum distance of 50 kilometres. Reaching out to a specialised doctor might be
over 150 kilometres travel, at times.
Over the last one decade this Desert has
undergone paradigm shifts. The life and
living in the desert is rapidly changing.
Influx of money in local economy and
influence of urbanisation are fast impacting and in many spheres affecting the
traditional systems. The medical facilities
have been improving and the communities are getting more aware and responsi-

ble on health, sanitation and institutional

services for health care, especially for
women and children. However, despite
this institutional, economical and social
change- inadequate access to healthcare,
nutrition, sanitation, and early learning
stimulation for children makes communities vulnerable. The social scenario
adds to their already weak nutritional
status especially of women. Gender discrimination, child marriage, large family
size and low literacy continue to affect
the marginalised in the community.
Appropriate medical facilities are only
available at the block level while any
specialised diagnosis and treatment can
be made only at the district headquarter
level. In spite of the implementation of
National Rural Health Mission, the system continues to lack in its reach. The
number of PHC and CHCs are limited
and are spread so far apart that one covers
an area of sometimes as large as 50-kilometre radius. Even at these health centres
the number of the patients that can be
catered to fall starkly short of the actual
need.
On the other end, any private medical
service is unavailable and if at all- it exists- it charges exorbitantly high. Infrastructural constraints are further intensified by lack of substantive knowledge,
awareness and behavioural limitations
about health. In these scenarios, to coun-

terbalance the above-mentioned issues,

the CHWs have been working in the
desert relentlessly for the last twenty-five
years. They have been providing basic
healthcare and facilitating in-time referrals to the communities. They also play
an important role as members of VHSC
to ensure health care systems and hygiene in the villages. They also volunteer
to bring a change in the spheres of education, childcare and early childhood development, livelihood and other development needs in the villages by sensitizing
and information bridging. Their efforts
and delivery makes them indispensible
in the development of their villages and
Dhanis. They have been working to organise community indigenously and to
help create a sustainable development led
by the community, which would drive
improvements in Health, Livelihoods,
Education, and most importantly create
a space for mother and child care with
special thrust on early childhood care
and holistic development.
This, here, is a comprehensive study
of twenty-five years of the CHWs efforts and inputs and the impact of this
in and on the communities. It is to congregate the qualitative insights of the
Primary Health Care programme and to
understand the interplay of the community health workers and the government
functionaries as it stands today and to ascertain a possible roadmap for the future.

Who are Community Health Workers?

ommunity Health Workers (CHWs)

are called by a variety of names including Health Auxiliaries, Barefoot
Doctors, Health Agents, Health Promoters, Family Welfare Educators, Health
Volunteers, Village Health Workers and
Community Health Aides. Here, in the
desert, they are locally called Swasthya
Sathin or Swasthya karmi. In these
frames or names their goal remains singularly in-focus - strive for a healthier
community not just confining to the
physical beings but working for the bigger system, causes and effects and in
short, the comprehensive well being of
community. CHWs deliver preventative
as well as basic curative medical services
at the very roots of social systems.
They are extensively trained volunteerworkers, working from within the community they belong to. They perform
variety of service delivery, motivational
and educational roles in primary health
care. They monitor the communitys
health, identify patients at particular risk,
act as liaisons between the community
and the health system and interpret the
social climate. They are practical means
of providing longevity and life to a
health program. CHWs help health care

systems overcome personnel and financial shortages by providing qualitatively

trained, cost-effective services to community members in their homes, and by
catching serious conditions at an early
stage, before they become more dangerous and expensive to treat.
CHWs spend most of their time making household visits, responding to simple treatment needs, conducting group
educational sessions, meeting with local
leaders, community-based organisations,
women and youth. They are, most often,
the only available means to reach parents
and children in their homes where the
majority of common health problems
originate and can be easily through simple practical measures be checked. Most
common health problems are due to lack
of hygiene and nutrition and to the lack
of income and education, and largely,
due to the weak status of women in the
family and community. Many communities lack the access to basic drug supplies, a need to which CHWs most often
respond.
CHWs help patients overcome obstacles to health care by accompanying
patients through treatment, monitoring
needs for food, housing, and safe water,

leading education campaigns and empowering community members to take

charge of their own health. They organise the community for preventive and
promotive activities necessary for primary health care. CHWs establish relationships of trust with their patients, bridging the gap between the clinic and the
community.
Responding to needs of the village, they
undertake provide the following responsibilities:
First-aid & treatment for minor illnesses
Check-up at the onset of pregnancy
Giving pre-post & natal advice, also
coordinating for safer institutional
deliveries
Encouraging institutional deliveries
Advocating ICDS & AWC for early
child care and development (ECCD)
Nutrition: monitoring, delivering and
educating
Immunization: monitoring, dispensing and educating
Family planning: services and advising
Sanitation and hygiene: educating as
well dispensing

Communicable disease screening,

monitoring, follow-up and medication
provision
Assisting in health centre activities
Making emergency referrals
Performing school health activities
Collecting vital statistics
Mobilization and financial empowerment of women, through Self-help
groups
Distributing medicines
Participating in community meetings
like those of Village Heath and Sanitation Committee (VHSC)

Community Health Workers and Urmul

For over two decades, Urmul has trained
and supported community health workers, as a response to community needs for
basic health services. Over 200 women
have been trained and work relentlessly
in Desert towards bettering of the health
services in the villages and dhanis. These
women have facilitated the organisation
of the community, motivated participation and increased ownership and accountability of the people towards health
care and availability of services. With
this vision of organizing community,
mobilizing collective action and developing skills for self-reliance, the programme was initiated with the training
of traditional birth attendants as Swasthya
Saathis or Community Health Workers.

The first batch of CHWs were incubated

and trained in 1986 to facilitate primary
health care in the villages and the remote
parts of the desert.
In those early years of the programme in
1980s and 90s, the formal healthcare system seldom reached the villages and was
inexistent in remote parts of this desert.
Understanding the need in the sphere of
health, community health workers were
identified as the best and inexpensive solution with high reach and accessibility
within the communities. It was realised
that it was exceptionally important to
educate the community about health
and health issues, remove the superstitions attached to it and then, address the
problems of accessibilities of reach of the

formal, both public and private, medical

systems. Urmul held its vision of leading the poor to self-reliance by making
available to them various developmental
services that they themselves decide on,
design, implement and eventually finance.

health care, maternal and infant health,

and ECCD- to increasing the linkages
to health services through formation of
womens groups, increasing accessibility
to formal systems and diversifying the
opportunities to livelihoods, directly as
well as improving linkages to financial
facilities.

Objectives and Strategy

The programme began with the support of Aga Khan foundation. Then,
Government of Rajasthan supported 30
Swathya Saathi in the first phase of the
programme through its fund for Border
Area Development fund in 1988. Later the
World Food Programme appreciated the
efforts of the CHWs and they through
CAD granted funds to replicate it in 150
villages in the canal area of Bikaner
Pugal, Khajuwala and Bajju. In 1996,
the Government of Rajasthan piloted
the Swasthya Karmi programme for two
years. This was withdrawn due to lack of
funds even though the programme was
much appreciated for the impact it created in the villages. This, however, went
on to influence the structuring, planning and strategizing the role of ASHA
and NRHM. Plan International through
extension sustained the efforts. Applauding the efforts, the team from Urmul
was asked to advice and train Swasthya
Karmis in Madhya Pradesh. The District
Poverty Initiative Programme (DPIP)
initiated a programme called Indira
Gandhi Garibi Hatao Yojana in Chttar-

Urmul saw the role of providing primary health care (hereinafter PHC) service
as an entry point through which various development services could be made.
Initially, the objectives were established
around the plan to provide basic health
and education services, focussing on the
reduction of maternal and infant mortality rates, increased access to health care
facilities, detection of endemic diseases,
like tuberculosis, and malaria, elimination
of night blindness and anaemia. Communitys participation and motivation
was of utmost importance for a comprehensive socioeconomic development.
The lack of income and education were
major reasons behind the unacceptable
state of Health. To address the issues in
health it was necessary to simultaneously
explore livelihood, encourage education,
with a special emphasis to girls education and improve the status of women in
the family and community.
Gradually, a divergence in the strategy
was needed. The thrust expanded from-

pur district. A team had also visited the

area on an exposure visit for experience
sharing.
Services, Delivery and Mechanisms
To carry out the laid objectives, Urmul
devised a three-tier strategy.
Village Level: At the village level, the
communities identified a local woman,
often a Traditional Birth Attendant or
a Dai, to be the Swasthya Sathis. The
community suggested and selected the
CHW. These women were trained to
provide pre, post and natal care; conduct safe deliveries; provide information,
educate and motivate for immunization,
monitor growth, nutrition and family
planning; treat minor ailments; identify
cases for referrals. After the selection,
each CHW was oriented and trained for
three months- the first month they were
trained theoretically at the Urmul Campuses. After the classroom training the
women went back to villages for twenty
days where they practiced their learning. After 10-day practical training the
women returned to the campus. Here,
they corresponded their field experiences
with theory and further trained to fill any
gaps that arose. These trainings were specially designed to help women learn and
practice with ease, for e.g. symbols and
pictures were extensively used as a mode
of training to overcome the barrier of lit-

eracy. Each CHW was given a medicine

kit with Safe Birthing Kit and a baby
weighing scale salter. She, in the start,
was paid an honorarium of 100 INR per
month along with an incentive payment
of INR 1 for each person registered and
INR 100 for each delivery.
Organisation support: The second tier
consisted of extension workers, professional staff who visited villages regularly.
In addition to support and supervising the
CHWs, these people provided a range of
preventive, promotive and curative care.
They also supported and motivated education and information on various themes
in the community.
Professional support: The programme
physician and cluster/field coordinators
made up the third tier. The physician
provided the basic medical care mainly
at the Urmul-run hospital in Bajju. The
physician along with the team made frequent visits to the villages addressing their
medical problems and also making referrals at the hospital in Bikaner. They also
organised and conducted various medical
camps in close partnership with public
healthcare system catering to different
diseases at different times from malaria
to TB, to Eye care to ENT camps. Apart
from the services in the field, the physician provided training to the CHWs and
was a source of constant support to any
need arising in the field area.

After the introduction of NRHM, the

CHWs make referrals to the ANMs, the
visiting doctors and also to the Government Hospital at Bikaner. . Health services include immunization, pre, intra
and post natal care, growth monitoring,
family planning, tuberculosis and malaria identification and treatment, distribution of vitamin, iron supplements to
deal with anaemia. The programme had
been and still continues to be integrated
with other programmes undertaken at
Urmul, to provide a holistic approach

to the overall development of the community. It had initiated various income

generation activities (wool spinning,
weaving, crop loans, seed banks, embroidery, livestock distribution), education
(non-formal education centres for children, six-month residential education
bridge camps, Sarva Shiksha Abhiyaan
and supporting Kasturba Gandhi Balika
Vidhalaya), agriculture (water supply,
rainwater harvesting, afforestation), and
community organisations (womens
groups, self-help groups, youth groups

10

and forums Bal mandals and Kishori

Prerna Manchs). All these are community led and based on participatory approach where Urmul primarily provides
linkages to various existing facilities and
motivates the community towards selfreliance and sustenance. Over the years,
witnessing the changes in the public facilities, the influxes in the society money and otherwise, and understanding the
need for self-reliance in the community,
Urmul has consciously withdrawn from

providing direct services and shifting

thrust in increasing the accessibility and
linkages to the formal available facilities
and systems. The shift has been towards
a rights based approach rather than service delivery. Even in the primary health
care programme, there continues the
first and second tier of system, but the
third tier has been willing dropped given
the improved public facilities, its accessibility and the implementation of National Rural Health Mission.

abri Bai, has worked as a Swasthya

Sathi for years in her village- 2 AD.
Remembering the time around 1996-97,
when Balika Shivirs were being initiated,
she narrates, Girls education was an absolute no-no. We did not even discuss this
in our society and in this happened the
Balika Shivirs. Who would send 12-15
year olds for six months to another place
and that too for education in those times.
One could not have imagined so. But I
wanted to send my daughter. I spoke
to many women in the village, tried to
coax them to see how good it would be
for our daughters. They will be able to
read, write and count. No one will be to
make a fool of her, like they do with us.
They will know better ways of looking
after children and homes, I said to them.
But they paid no heed. Actually it was the
men who were difficult to convince.
Nonetheless Babri Bai brought her
daughter, Chandu, to the shivir. Chandu
finished her primary education and continued to school in the village till class
eight. Chandu wanted to continue school
but the village school was only up to class
eight, so Babri Bai sent her to Bikaner to
continue school. Here, she finished her
class ten and twelve. Today, she is in the
final year of B.A. degree and pursuing
Bachelors in Education. She wants to be
a teacher. Babri Bai says proudly, Today
those same people who refused to send

their daughters, regret their decisions

when they see Chandu. They tell me,
you were right Babri Bai. You were
right about everything. Our daughters
could have also had the opportunities like
Chandu. Now everyone is sending their
children to school. This makes me happy.
One Chandu in the village has changed
so many.
12

Swasthya Sathin in Action

he challenges cannot be fully addressed by the current formal systems of healthcare facilities. To establish
and understand the role of Swasthya Sathis or CHWs, it is essential to understand the deep involvement, evolution
and adaptation, of these women and the
function they have played in improving and sustaining the village health and
most importantly, linking it with the formal system. It is of utmost importance to
comprehend the roles these women play
in the frame of reference of the social milieu in which they operate and the difficulties they posed with everyday. It is also
very necessary to see them in different
contexts for the holistic development they
have facilitated in the villages.
Health
The CHWs have been working to uplift
the health standards and facilities in the
villages. With remote accessibility, even
immediate first aid in case of emergencies improves drastically the chances of
survival and this has been the motto for
CHWs and the programme. The CHWs
have been working in the region for more

13

than two decades and deeply understand

the health needs and social systems. The
CHWs play three essential roles in the
sphere of Health.
Direct delivery of services
Advocacy
Monitoring community Health
The CHWs are trained to provide three
post natal care, conduct safe deliveries,
provide information, educate and motive, immunization, growth monitoring,
nutrition and family planning; treat minor ailment; identify those who require
referral. Given the low levels of nutrition
in the villages, they closely monitor nutrition levels in the village, especially of
children and adolescent girls.
Womens health is of utmost priority.
Health concerns among women are kept
under wraps and are not discussed until
they reach an acute stage where the implications become severe. To avoid this
CHWs closely monitor women and adolescents health. Leucorrhoea and anaemia is common among women and girls
but due to the social atmosphere, this is
not treated. The CHWs make sure this

and other concerns are raised and treated

within time. They give iron supplements
to adolescent girls. To promote sanitation
and hygiene, CHWs dispense sanitary
napkins. They check-up women on the
onset of pregnancy and during pregnancy, they keep a close watch, to ensure the
growth of the baby is right, the mother
is healthy and complications are avoided.
The CHWs assist in the organization of
medical camps by professional doctors
and nurses, in the villages. With limited
accessibility, medical camps are till date
organized to provide professional medical assistance to complicated cases. Here,
the CHWs play a vital role in bringing
the screened patients for treatment. This
improves the effectiveness and reach of
the camp and the people receive necessary care and treatment.
Since the implementation of the NRHM,
the health services have become the responsibility of the ANM and ASHA; the
CHWs assist them in these services. Even
when a delivery is about to take place, or a
woman becomes pregnant or if someone
falls sick the CHW is contacted first and
she calls on the ANM and ASHA. This is
primarily due to the years of association
in the village. She assists in institutional
deliveries, immunization and providing
nutritional supplements also. She supports health centre activities. The ASHAs

find it easier to find a footing in the village where a CHW is available. The village people are aware and sensitized towards health and health concerns and the
ASHAs take the help of CHWs to reach
out to people.
However, many of the villages still do not
have an appointed ASHA. This is because
of two main reasons, firstly, the literacy
level in the villages is very low and the
women do not fulfil the basic qualification of the criterion. Secondly, the ASHA
works on incentive basis and this does attract attention of the women to take up the
job. CHWs play a pivotal role in sensitizing people and raising awareness on various issues. They create an environment of
understanding and information in place
of superstitions and tantric practices, remove doubts and strengthen faith in the
modern medical system. They propagate
health and hygiene practices, insist on
cleanliness and also encourage environmental protection for better health. They
insist on clean drinking water and keeping hygiene around the village. They encourage institutional deliveries; adopting
family planning measures, give necessary
pre post & intra natal and childcare advice. They educate pregnant and lactating women about nutrition, monitoring
it and about breast-feeding and nutritional supplements. They also advocate
immunization, educate, especially to-be

14

Now people call us as soon as

they need any help. But when I
started, I had to plead with them
to take medication, come with me to
the camps or to the doctor. Most difficult was to take men or women for
vasectomy or Tubal ligation. But now
after so many years efforts people are
realising the benefits of a smaller family. Also, now the society has become
more open to this concept. I have also
motivated my son to get operated. He
has one son and a daughter.

and new mothers, about importance of

immunization. They promote sanitation
and hygiene and give even basic training
about sanitary napkins, how make them
easily at home and to use them regularly.
The third health function that the
CHWs carry out is of monitoring the
health status of the village. They keep a
close watch on the health and illness patterns in the village. They are trained in
maintaining a record and database for the
village. This provides vitals statistics for
the continued analysis of the health in the
villages. As VHSC members, in some villages, they help in proper planning and
implementation of health and hygiene
related activities and practices

15

Education
Urmul has been facilitating educational
programmes in the region. Over the years
more than 10000 children, out of whom
more than 80 % are girls, have been educated. Illiterate- the women found it very
difficult to grasp and memorise medicines and information about diseases.
They realised they would have had to put
in much less effort than they already did
had they been educated. Seeing how education impacted life and living all across,
they were motivated to send their children, both boys and girls to schools. The
CHWs as volunteers have since played a
pivotal role in supporting and strengthening the education programmes. They
helped in initiating an environment congenial to education, especially for the girl
child. They, themselves, were uneducated, but working and training as CHWs,
they realized the importance of education. They wanted all children to be educated so they could help explore stronger
and better possibilities for them and the
village. They were now more appreciated
and accepted in the society because of
their efforts by now. They persuaded and
convinced people to send their children
to school, explained to them how this
would untie opportunities and was necessary for future. Few agreed and few did
not. However, it did initiate the thought

in the minds of the people. They began

contemplating education as an option
for girls this was the biggest achievement. Few, who understood, sent their
daughters and sons, to village schools, or
Urmul-run Marushalas (primary schools)
and Balika Shivirs (residential education
bridge camps) When these first generation of learners began to display changed
attitudes and behaviour, even those who
had been sceptical sent they children,
both daughters and sons to school.
ECCD and Child Rights Advocacy
Care and development of children is a primary responsibility of the family, community and local governance. Urmuls
engagement with early childhood initiatives is over two-decade old. It has been
the implementing agency of the ICDS
programme in the Kolayat block of Bikaner since 1991. This helps integrate efforts at various levels. CHWs along with
the Anganwadi workers, youth forums
- Kishori Prerna Manchs & Bal Manchs,
Prerak Dals, VHSCs, SMCs, and SHGs,
help to strengthen endeavours with the
villages. Child rights and protection of
these rights is of utmost importance.
CHWs have played a pivotal role in scuring these, over the years. They promote
early childcare and development and ensure child rights and insist that the chil

I have been an ASHA in the village for three years now. When I
first started it was very difficult to
approach all homes, especially because
Im the daughter-in-law. But because
the Swasthya Saathin was there I managed to easily find my way in. It helps
in cases especially where some families
are adamant or superstitious and do not
want to seek medical aid, there both of
us go and explain. Because the CHW
has been working for years people pay
more attention to what she is saying
and they listen more easily.

dren are sent to Anganwadi Centres to

They propagate against child marriage
and gender discriminations deeply embedded in the society. They work on malnutrition and creating conducive learning environments so children develop
their physical, cognitive and social skills.
Over the years they have been instrumental in reducing the numbers of child
marriages in the villages though continuous efforts. They take part in awareness
drives, village-level meetings, panchayats
and the Mother-Child Health and Nutrition Day and meetings to talk to people
in the village at various levels and to ensure child rights.

16

iving at the borders of the country,

life, least said, is eventful. People
and places are on the line of control and
treated as No Mans Land. Badu Bai
lived in village Ravwala. People would
come from far off villages to consult her
and take her with them on their camels
for deliveries. She was excellent with her
hands and could take care of even the
most complicated cases with confidence.
Once on route, the mobile hospital was
in her village. The ANM was delivering
a pregnancy. The case was complicated.
The foetus was in a breach position and
the ANM was finding it difficult to deliver the baby. She consulted the doctors
on-board on the mobile hospital. They
examined the foetal position and the
mother. They realised that they needed better medical assistance. Time was
passing and the case was complicating.
They were readying to take the woman

Livelihood
The CHWs mobilize women to form
Self-Help Groups in their villages for
capacity building and empowering the
women financially and vocationally. Given the unreliability of agriculture and
lack of options to livelihoods, SHGs savings and access to loans supports the fam-

17

in labour to Bikaner- around 150 kms,

to operate and deliver the baby.
Just then, Badu Bai arrived. She examined the woman and realised the situation. Using her bare hands, she massaged the womans stomach and in the
next fifteen minutes the baby was delivered. The mother and child both, were
safe. Her traditional expertise and her
experience were her strengths. Badu Bai
used the modern procedural knowledge.
She was later trained to treat various basic and endemic health ailments in her
village. The possibility of making referrals for more complex cases was the
biggest assistance she received in her endeavours. People trusted in her and this
possibility elevated their confidence. She
drew a fine balance between the traditional and the modern knowledge. She
worked hard to ensure health in her border village till her demise.

ilies at times of crises. This gives women

financial space and make them a valued
member in families. The SHGs also help
in other development programmes, like
Income Generation Programme- for
women artisans embroidering for a living. They are not exploited by middlemen and generate a regular source of income this way.

In 1988 when the programme was

first initiated, the toughest task
was to get the women to the Bajju
campus for training. The Patriarchal society did not allow women to come out
of their homes. The closed society was
sceptical of the intentions of the organization. A male family member accompanied women then. Seeing the safety they
would leave in a day or two, carrying

with them a positive feedback to the village. This initiated the cycle of change.
Over the years, the scenarios changed
so much that many CHWs and other
women have travelled many places with
confidence.
(Pushpa Purohit, Secretary at Urmul Seemant Samiti, has been associated with
CHW programme since its beginning)

18

The experience

n 1988, Urmul expanded its primary

health care programme to the Kolayat Block of Bikaner district from
Lunkaransar and Phalodi. In consonance
with the objectives of the programme,
local women (in most cases the Traditional Birth Attendant of the village)
were chosen- firstly the women were
more likely to gain the trust of people as
people were used to calling them upon
various instance of health concerns especially, those dealing with women and
children. This provided a chance to directly monitor and evaluate the rising
rates of maternal and infant mortality.
Secondly, the women already had vast
experience of traditional health practices
and were more easily trained in modern
medical techniques to gain expertise as

19

a barefoot doctor. They were provided

with a Para-surgical medical toolkit- that
was well equipped for first aid with ointments, bandages and tincture and also included general health care medicines like
paracetamol, Ibuprofen, Antacid, Iron
and Calcium supplements, eye drops.
The community health workers were
also given a baby weighing scale salter
to monitor malnutrition in the community. Thirdly, the exposure, service, and
financial assistance would improve her
status in the family and community.
Initiating the programme was exceptionally difficult. Subservient status of
women in society, the purdah or the veiling system and forbiddance of leaving
home for women, were the biggest bar-

riers in this social environment. The programme encouraged women to step out
of their villages, come to Urmul campus
(in Bajju) for trainings, and make regular
visits in their specified field areas. CHWs
would go about each house, irrespective
of the caste and class and provide healthcare services. This received much scorn
from the society initially. Against social
pressures, 25 women were motivated
enough to undertake the responsibility
of their respective villages and Dhanis.
Two of these were asked to leave their
community and a few dropped out owing to external pressures but 17 of them
continued. When they went back, they
were met with bigger challenges than
just health problems. The village community was unaccepting. The prejudices
held against women, the lack of understanding of health and its problems, and
superstitions hindered their acceptance.
After continuous efforts, the women
gradually began changing the attitudes
of the people towards medicine and
healthcare practices. When practices and
medicines began showing their impact
and bettering health, the faith in them
and the women grew proportionately.
The consequence of this was that the
women were perceived as well wishers
of the community and so won the position of opinion leaders. Over time, these
women have transformed and changed
their societies. They have been motivating women and men all these years

to join in the efforts and encapsulated

an enormous indigenous support from
within the communities. This innovatively localized the programme and
helped further adapt and up-scale.
The CHWs underwent regular training programmes to learn various new
techniques, about new medicines and
also learn to identify symptoms of various diseases that affected the region at
various times and to refresh, most importantly, what they already knew. Various doctors from government hospitals
and head nurses conducted these trainings. In the course of time, the Swasthya
Sathis or CHWs proved to be much more
than mere village health workers. They
volunteered to act as resource and lead
persons for their villages. They volunteered to support and promote education,
livelihood options, micro-finance and
sanitation in the villages. Even today they
stand in as an interface between Urmul
and the village community, helping build
a strong base within the community.
They have become a reference point for
information on a variety of issues; water,
land rights, employment, education, etc.
People trust in them and seek advice on
matters of concerns.
Today, there are more than 50 of such
women covering as many villages directly. Additionally they are also called on by
nearby villages to provide the necessary
20

care, supporting the medical mainframe

as well as strengthening and fortifying
programmes in education, women mobilization, livelihoods, etc. These women
have become a nodal point in a comprehensive healthcare delivery platform for
the village. When Urmul initiated its
programme in the region, almost fifty per
cent of infant mortality in Rajasthan was
neonatal and perinatal, resulting from
lack of effective antenatal and postnatal
care. This interface was then largely in the
control of the dais. The Indira Gandhi
Canal project in its wake brought along
with it a few drawbacks and one amongst
these was the wide spread of malaria. This
aggravated the already deplorable conditions of health. The communities suffered. Lack of proper medical facilities did
nothing to reduce or help. The CHWs
became the only resource available to
check and balance the health status of
`the communities. They were trained to
identify and diagnose fever from malaria,
carry out safer child deliveries and arrest
smaller ailments. They made the necessary referrals to doctors.
Over the years, the health care facilities
have improved and Government initiatives in the form of physical health care
units as well as the schemes have been
more accessible. Introduction of ASHA,
ANM and Village Health and Sanitation
Committee in the network have helped

21

fasten the pace of improvement. These

units, together, help in holistic monitoring of health in the village. The ASHA
and ANM dispense regular health care
and along with the VHSC keep a close
watch on the status in the villages. However, there are still villages in the region
that do not have an ASHA, ANM or a
working VHSC in their vicinity. These
communities remain vulnerable and riskprone. The only solution, at times available, for health care facility is the one
provided by the CHWs, who regularly
visit and keep a check on the health of
the community or village.
New Developments: NRHM
Addressing the need for a concerted targeting of health in rural India, the government introduced National Rural Health
Mission (NRHM). The government of
Rajasthan launched the implementation
in 2006. This was to address the growing
concerns of increase in communicable
and non-communicable diseases coupled
with poor health facilities in the rural
areas and resultant high infant mortality
rates and maternal mortality rates. The
objective of the mission is to provide efficient and affordable health care services,
to improve the rural health infrastructure,
ensuring adequate presence of healthcare
workforce and addressing local needs
and concerns especially the concerns of
alarming sex ratio and the low status of

tion committees (VHSCs), as a means of

fostering a true partnership between the
community and peripheral health staff in
achieving desired outcomes.
Nevertheless, the sheer enormity involved in servicing a population as large
as ours calls for integrated macroeconomic and grassroots level efforts to improve the rural health infrastructure and
address local needs and concerns. Within
Rajasthan the area as is divided on topology as it is on socio-cultural background
of the people. The issues become unique
to the geography as well as the varied
culture attached to it. Thus the one size
fits all phenomenon does not help resolve
the issues but aggravates them.

the girl child. The NRHM provides for a

flexible financial pool for innovative and
need-based decentralized utilization of
funds at the state level, along side conditions for planning and management at the
district level. Furthermore, the creation
of female Health Activists (ASHAs) and
PRIs, such as village health and sanita-

Moreover, political and administrative

will and capability of implementation of
the programme along with constraints in
ascertaining the required workforce further hinder the programme. The social
milieu is unfavourable towards women
education. It causes difficulty in the appointment of ASHAs based on the norms
prescribed. Even though the education
qualification is brought down to class 5
from class 10, there is acute shortage of
qualified women in the villages. Further, the distances make it very difficult
to achieve a full coverage of service and
infrastructure. Thus it becomes essential,
to understand the role the CHW play in
improving the health of community.

22

Challenges
Despite all the efforts, public formal medical system, the NRHM and the private
sector, the Kolayat block in particular is
still face with major challenges. These
challenges not only diminish the possibilities in the current scenario but also
inhibit further growth. Few major challenges are elaborated below:
Health Facilities and lack of easy access
poses the major problem in the Kolayat
block. The medical facilities are available
at either the block level or at the district
levels. Health situation is characterized by
infrastructural constraint. There is only
one tenth of CHC with beds in the Bajju
sub-tehsil area, which caters about 1 lakh
population supported with just 2 Primary
Health Centres (PHCs). The CHC delivery room does not have the facilities for
the emergency Caesarean Section. Only
one private health clinic in Bajju other
than the Govt. administrated health centers supports the population. Infrastructural constraints are intensified by lack of
substantive health management knowledge and awareness and behavioural limitations.
Despite the implementation of NRHM,
numbers of ASHAs are limited in the villages. The ASHA is usually appointed at
the Gram Panchayat level. This limits her
capacity to reach all villages under the

23

Gram Panchayats purview regularly. The

healthcare monitoring slackens.
The limited numbers of CHWs limits
their reach in the region and does not
comprehensively address the enormous
needs of the entire area.
Literacy among the women in the rural
areas is as low as 8.84%. Lack of literacy
poses a hindrance in the access of health
care, high birth rates and a large family
size. The rate of anaemia is common and
found in over 50% of women. This rate
rises to 82.3% in new-borns. Leucorrhoea and pelvic inflammatory disease
rate is very high.
High mortality among under-5 children is primarily due to ARI, diarrhoea
and vaccine-preventable diseases. Low
awareness of the symptoms of the childhood diseases and its proper care and cure
add to the magnitude of the problem.
43.7% of children below five years of
age are stunted; exclusive breastfeeding
and complementary feeding of children
remain significant challenges (NFHS,
2005/6).High mal nutrition levels in the
village increase the risk to health. The
children are born underweight and the
lack of sufficient nutritional supplement
remains malnourished and thus prone to
diseases.
According to data by the WCD depart-

ment, there are 48,372 ICDS centres in

the state, benefiting 110 lakh children.
The supplementary nutrition component
of ICDS is benefiting around 39.26 lakh
children and preschools are benefiting
12.60 lakh children in the state.
Socio- cultural factors make women
susceptible to ill health leading to high
risk pregnancies, child morbidity and
mortality and reduced capacity for taking
care of the child low literacy level leading to low awareness, lowest sex ratios in
the state (917, census 2001); median age
of 17 years of marriage for girls (DLHS

2005-06), early pregnancy (19% women

of 15-19 years were mothers or pregnant)
48% girls get married before the age of
18 years; with only 40% couples adopting family planning methods, frequent
pregnancies and high risked child births
the health of the mother further deteriorates, leading to more complications
to the health of both, mother and child.
The percentage of women at risk during
and post pregnancy stands at 17.9% and
31.2% respectively (DLHS, 2005). The
17 percent of adolescent girls in the age
group of 14-24 year olds have access to
24

adequate information and training on reproductive and sexual health, making the
situation graver.
According to Baseline Survey of Urmul
Seemant Samitee conducted in 2009, only
23% of expectant mothers had received
the right number of pre-natal check-ups
(3 or more check-ups) and skilled birth
attendants attended only 42% of deliveries.
Only 16% of children in age group of
12-23 months have received complete
immunization. Alarming 43.5% children
were malnourished in the age below 5 yrs.
Lack of Information in people aggravates the already deplorable conditions.
People have limited knowledge about
the various schemes offered by the medical and health department. Low rate and
incomplete immunization and childhood
illnesses are attributed to low levels of
awareness among mothers/ communities.
Looking Ahead
The last twenty years, CHWs have nurtured and nourished health of the society
and its people in the remote regions of
the Desert. Based as they have been on
significant community education and capacity building, it is not surprising that
the programme has been particularly effective in generating demand for preventive and promotive health services. To

25

a large extend they have also increased

the use of prenatal care and family planning. The programme has been successful checking the high rates of maternal
and infant mortality, high incidences of
endemic and non-endemic diseases and
disorders. It is now time to reassess the
situation and pave way for the future of
health in communities and CHWs as role
players. Some key pointers deserving attention are mentioned ahead.
Today, the increasing demands of health
and complications require a positive restructuring of the role of community
health workers in the community. These
are a trained resource for health in the
villages. They have built trust and confidence in the people. More adaptive and
solutions based approach in the villages
will further help decrease the scepticism
in seeking medical advice and assistance.
It is now, more than ever, necessary to
further strengthen their capacities and
to incorporate their traditional knowhow with advanced trainings in primary
health care. Alternative medical sciences,
like Ayurveda and Unani, can be good
additions to the wide base of their knowledge. Their traditional knowledge, which
is entirely based on these streams, would
widen the scope of their capacities.
Sustainability is a major criterion. The
women are, currently paid a small fee of
Rs 800 a month, along with the money

they earn by selling medicines. Now that

the state government has subsidized medicines completely, they will earn only Rs.
800. Newer avenues need to be explored
for these women possibilities of attaching them to MGNREGA or the Gram
Panchayat could be explored.

Workers have established a trusted relationship with the communities. The

communities pay attention to and follow
the advice the women render them. They
have been fighting the cause of social injustice, gender discrimination and child
rights.

The free medicines do not reach Dhanis and remote villages and remain at
the levels of PHC, CHC and ANM. To
widen the reach CHWs could play a vital
role. They are trained in identifying and
dispensing medicines and the possibilities
could be explored with the government.

Community health workers work along

with the ASHA and facilitate their workings. Community health workers are usually older women in the village while the
ASHA are usually the daughters-in-law.
Given the patriarchal set up of the communities in the villages as well as the feudalistic composition, it becomes difficult
for the younger ASHA to enter homes,
and generate personal information about
health from the families.

Community Health Workers are well

trained, adept and equipped in providing
healthcare and handling first aid in case
of emergencies. Their illiteracy does not
pose any threat to the health of others.
Community health workers, at many
villages are the only source of basic
healthcare. Many villages do not have
ASHA appointed in the villages. Some
panchayats govern more than three or
four villages spread over at a radius of 3040 kilometres. In such cases, it becomes
impossible for the ASHA to be available
at each village. This problem aggravates
during the cultivation season, when families move from the villages to their dhani
(a house on the farmlands). This makes
reaching them even more difficult.

Community health workers facilitate

the community in mobilization and empowerment of women, childcare, livelihoods, etc. Therefore contributing to the
holistic development of the entire community and village.
Community health workers are the very
essential but missing link in the formal
healthcare system. Even those places that
had both an ASHA and the community
health worker were better in health status.
The ASHA and CHW worked in unison
and had a better outreach.

Over the years, Community Health

26

hapu Bai is fondly called Dhapu

Dadi by people in Urmul, her
community, her village and all who
know her. She is a board member of the
organisation, Urmul Seemant Samiti Ba27

jju. This old woman is illiterate and had

never travelled across the boundaries of
her dhani. She had heard stories of lands
of greens, prosperity and life. But for her
life was living in a Dhani in a place wish-

fully called Chila Kashmir. It is a piece

of land covered with miles and miles of
sand and is situated at the west-end of
the country, bordering with Pakistan on
one side. It is dry, barren and without water through out the year. Road does not
reach this place and the only transport
found is the camel-cart or a long walk.
Dhapu dadi was a dai in the community
and was approached to work as the community health worker when the programme began. At first she was hesitant
but it did not take to much convincing.
She was a widow and this, she saw as an
opportunity to find her financial sustenance. Dhapu dadi was among the first
twenty-five women who dared to step
out of home and change their worlds.
She remembers going to the first training
at the Urmul campus at Bajju. She found
the names of the new medicine funny
and difficult to remember. It was the
case with all of us. Then we learnt to recognise the shape and sizes of the different
tablets and registered them to memory
using these. When we first went to the

villages, people did not believe in us. We

had been delivering their children for
years - that was fine, but when it came to
treating them with medicines they said
the medicines would harm them. Gradually the changes that came by with the
medicines, the referrals and the camps
instilled the communitys faith. Today,
for everything they still come to me even
when I dont keep medicines anymore,
she fondly narrates her journey. She has
worked here tirelessly for the last twentyfive years for the health and welfare of
her people. Working to change and lift
the status of women in the community,
leading many a crusades in the desert
to awaken people towards the depleting
ecology, impact of the Indira Gandhi canal on health, maternal and child care,
education and livelihood.
It is here that the winds carried her
songs to the lands wide and far, praying
them to turn their attentions awhile to
this place never reached. She sang to her
countrymen in anger, agony and pain,
hoping them to see life and its tales.
28

Annexure 1
Name of CHW

Village

Patients Treated (per year)

2010

Month
(Avg)

2011

Month
(Avg)

Presence of
ASHA

Jawradevi

15khd

238

20

261

22

No AWC

Kasturi Devi

Bhagdsar

251

21

206

17

Yes

Sugni Devi

1KHD

166

14

180

15

No AWC

Teji Devi

19CWB Charanwala

204

17

228

19

Yes

Noja Devi

12KHD Charanwala

286

24

335

28

No AWC

Shanti Devi

Gokul 5RSM

231

19

144

12

No AWC

Badu Devi

Chanranwala

130

11

157

13

Yes

Lakshmi Devi

11KHD Charanwala

311

26

192

16

No AWC

Sammudevi

17CWB Chanranwala

183

15

170

14

No AWC

Barju Devi

Chila Kashmir

159

13

230

19

Yes

Dhapu Devi

8 DOBB Mankasar

327

27

288

24

No AWC

Mukhi Devi

24KLD Bhurasar

155

13

238

20

No AWC

Devi

1CD Chila

219

18

206

17

No AWC

Gawradevi

3DOBB Bhagdasar

145

12

144

12

No AWC

Penpa Devi

888 Bhagdasar

167

14

191

16

No AWC

Kasini Devi

Kolasar

181

15

370

31

Yes (2 ASHAs)

Khatu Devi

100RD Bhadal

506

42

276

23

N/A

Reshma Devi

2MTR Mithadiya

194

16

266

22

No AWC

Hurma Devi

Lakhasar

190

16

299

25

N/A

Ganga Devi

Mankasar

193

16

264

22

Yes

Lali Devi

3DOBB Bhagdasar

242

20

323

27

No AWC

Parmi Devi

888 Bhagdasar

286

24

217

18

No AWC

Saraswati Devi

6 BR Barsalpur

201

17

252

21

No AWC

Santosh Devi

Karndarli

206

17

181

15

Yes

Chauthi Devi

Pabusar

239

20

289

24

N/A

Jani Devi

Miyanka

144

12

214

18

N/A

Nathi Devi

Khara Lohan

444

37

213

18

N/A

Mohini Devi

Haddan

289

24

278

23

1 out of 4

Table displaying the Work of CHWs

Name of CHW

Village

Patients Treated (per year)

2010

Month
(Avg)

2011

Month
(Avg)

Presence of
ASHA

Kamla Devi

Siyana

217

36

286

24

Yes

Shayar Devi

Jhajhu

387

65

202

17

1 out of 3

Soni Devi

Khindasar

301

25

182

15

Yes

Sohan Kanwar

Banlan Ki Gol

300

25

214

18

Yes

Jamuna Devi

Bheloo

238

20

349

29

Yes

Lakshmi Devi

Barupalon Ki Dhani

193

16

373

31

Yes

Gomti Devi

Thumeli

206

17

346

29

Yes

Maghi Devi

Haddan

300

25

239

20

Yes

Rami Devi

Nainiya

250

21

239

20

N/A

Manhori Devi

Khakhusar

455

38

203

17

Yes

Nainu Devi

Bhatiyon ki Dhani

299

25

337

28

Yes

Chini Devi

Sevro ki Dhani

513

43

286

24

No AWC

Kailashi Devi

Hanumannagar - Bheloo 238

20

258

22

Yes

Khamma Devi

Lohiya

300

25

252

21

Undetermined
leave

Gowra Devi

Siyana Bhatiyaan

238

20

252

21

Yes

Phooli Devi

Siyana Kundliyaan

292

24

178

15

Yes

Chunni Devi

Khiyaaram Nagar

286

24

254

21

Info unavailable

Pappu Devi

Chimanna

410

34

310

26

Info unavailable

Sua Devi

Chimanna

337

28

322

27

Info unavailable

Jamuna Devi

Govindpur

289

24

194

16

Info unavailable

Nasiba Devi

Khajhusar

266

22

250

21

Info unavailable

Moomal

Imamnagar

276

23

275

23

Info unavailable

Nainu Devi

Lakshmannagar

254

21

286

24

Info unavailable

Jamuna Devi

Kisan Nagar

241

20

265

22

Info unavailable

Radha Devi

Ganesh Nagar

325

27

299

25

Info unavailable

Gawra Kanwar

Siyana

222

19

263

22

Yes

Table displaying the Work of CHWs

600
500
400
300
200
100
0
Miyanka

2010
2011

Karndarli
Pabusar

6 BR Barsalpur

888 Bhagdasar

3DOBB

Mankasar

Lakhasar

2MTR

100RD Bhadal

Kolasar

888 Bhagdasar

3DOBB

1CD Chila

24KLD

8 DOBB

Chila Kashmir

17CWB

11KHD

Chanranwala

Gokul 5RSM

12KHD

19CWB

1KHD

Siyana

Number of PaMents Treated Year 2011

Ganesh

Kisan Nagar

Lakshmanna

Imamnagar

Khajhusar

Govindpur

Chimanna

Chimanna

Khiyaaram

Siyana

Siyana

Lohiya

Number of PaMents Treated Year 2010

Hanumanna

Sevro ki

BhaByon ki

Khakhusar

Nainiya

Haddan

Thumeli

Barupalon

Bheloo

Banlan Ki

Khindasar

Jhajhu

Siyana

Haddan

Bhagdsar

15khd

600
500
400
300
200
100
0

Khara Lohan

Annexure 2

The Charts illustrates the current pattern of health status in the villages were the
programme is operational. It highlights the number of patients treated and referred
by the CHWs in the villages in a year. It also draws attention to the presence of
ASHA in the villages. It highlights the fact that despite the presence of an ASHA,
the CHW still plays a vital role in treating patients in the villages for common
diseases and referring them in case of acute cases. Where there are still no ASHAs,
CHWs are the only possible response to all health related issues in the desert.
Key pointers
The number of patients treated in a year vary between a minimum of 159 and as
high as 513 displaying the varied status of health in the region.
The average number of cases of the total villages decreased by 4%
44% villages showed a rise in number of cases in the 2011 when compared to the
2010 due to lack of services and ease of accessibilities
33% villages showed a fall in the number of cases. The fall in numbers is significantly high- Bhadal, Khakhusar, Khara Lohan, Sevro ki Dhani, Khindasar, Chimana specifically. Four of these villages do not have any formal health services and
rely only on CHWs.
37% percent villages in the programme area do not have an ASHA
8% percent of villages have under appointment of the number of ASHAs required
in the village. Many villages have an Anganwadi Centre, but no appointed ASHA

Mukhi Devi, Santosh Devi, Khatu Devi, Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti D
Devi, Premi Devi, Hurma Devi, Ganwara Devi, Ganga Devi, Devi, Barju Devi, Reshami, S
Devi, Nasiba, Shayar Devi, Kailashi Devi, Jamana Devi, Nathi Devi, Laxmi Devi, Gomati,
Mukhi Devi,
SantoshNenu
Devi, Khatu
Devi, Shakari
Devi, Jawara
Devi, Tijan,
Laxmi,
Shanti Devi,
Dhapu Devi,
Kisturi, Noja
Devi, Devi, Muk
Devi, Chhini
Devi,
Devi,
Kamala
Devi,
Rami
Devi,
Vidha
Kanwar,
Muli
Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi, Ganwara Devi, Ganga Devi, Devi, Barju
Dhapu Devi,
Kisturi, Noja Devi, Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi
Devi, Reshami, Samu Devi, Nenu Devi, Pappu Devi, Mumal, Radha Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar
Devi, Kailashi
Jamana Devi,
Devi, Nathi
Devi, LaxmiRadha
Devi, Gomati,
Ganwara
Devi,Devi,
Shohan Kanwar,
Khama
Devi, Mohini,
Devi, Nenu
Devi,Devi,
Pappu
Mumal,
Devi,
Sua
Chuni
Devi,
Jamana Devi, N
Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu Devi, Kamala Devi, Rami Devi, Vidha Kanwar, Muli Devi
Devi, Shohan Kanwar, Khama Devi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhin
tosh Devi, Khatu Devi, Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi,
Hurma Devi, Ganwara Devi, Ganga Devi, Devi, Barju Devi, Reshami, Samu Devi, Nenu D
Devi, Kailashi Devi, Jamana Devi, Nathi Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan
Devi, Kamala Devi, Rami Devi, Vidha Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Kha
Devi, Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi
Devi, Mumal, Radha Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar Devi, Kaila
Khama Devi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu Devi, Ka
Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi, Kisturi, Noja Devi, Sug
Devi, Ganga Devi, Devi, Barju Devi, Reshami, Samu Devi, Nenu Devi, Pappu Devi, Mum
Jamana Devi, NathiOver
Devi, Laxmi
Devi, Gomati, Ganwara Devi, Shohan Kanwar, Khama De
25 years,
tosh Devi, Khatu Devi, Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi,
the programme has been
Hurma Devi, Ganwara Devi, Ganga Devi, Devi, Barju Devi, Reshami, Samu Devi, Nenu D
Devi, Kailashi Devi,supported
Jamana Devi,by:
Nathi Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan
Devi, Kamala Devi, Rami Devi, Vidha Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Kha
Devi, Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi
Devi, Mumal, Radha
Devi, Sua
Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar Devi, Kaila
Aga Khan
Foundation
Khama Devi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu Devi, Ka
Shakari Devi,
Jawara
Devi,
Tijan, Laxmi,ProShanti Devi, Dhapu Devi, Kisturi, Noja Devi, Sug
Border
Area
Development
Devi, Ganga Devi, Devi,
Barju Devi, Reshami, Samu Devi, Nenu Devi, Pappu Devi, Mum
gramme,
Jamana Devi, Nathi Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan Kanwar, Khama Dev
Ministry of HRD, GoI
Rami Devi, Vidha Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Khatu Devi, Shakari De
Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi, Ganwara Devi, Gan
CAD IGNP
Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar Devi, Kailashi Devi, Jamana Devi
World
Programme
Maghi Kanwar,
Phuli Food
Devi, Jyani
Devi, Chhini Devi, Nenu Devi, Kamala Devi, Rami Devi
Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi, Kisturi, Noja Devi, Sugani Devi, Chothi De
ActionAid
Devi, Barju Devi, Reshami,
Samu Devi, Nenu Devi, Pappu Devi, Mumal, Radha Devi, Sua
Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan Kanwar, Khama Devi, Mohini, Maghi K
International
Devi, Chuni Devi,Plan
Jamana
Devi, Nasiba, Shayar Devi, Kailashi Devi, Jamana Devi, Nathi D
Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu Devi, Kamala Devi, Rami Devi, Vidha K
Plan
India
jan, Laxmi, Shanti Devi,
Dhapu
Devi, Kisturi, Noja Devi, Sugani Devi, Chothi Devi, Kishan
Devi, Reshami, Samu Devi, Nenu Devi, Pappu Devi, Mumal, Radha Devi, Sua Devi, Chun

Devi, Dhapu Devi, Kisturi, Noja Devi, Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu
Samu Devi, Nenu Devi, Pappu Devi, Mumal, Radha Devi, Sua Devi, Chuni Devi, Jamana
Ganwara Devi, Shohan Kanwar, Khama Devi, Mohini, Maghi Kanwar, Phuli Devi, Jyani
khi Devi, Santosh Devi, Khatu Devi, Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti Devi,
i, Premi Devi, Hurma Devi, Ganwara Devi, Ganga Devi, Devi, Barju Devi, Reshami, Samu
Nasiba, Shayar Devi, Kailashi Devi, Jamana Devi, Nathi Devi, Laxmi Devi, Gomati, Ganwara
ni Devi, Nenu Devi, Kamala Devi, Rami Devi, Vidha Kanwar, Muli Devi, Mukhi Devi, SanKisturi, Noja Devi, Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi,
Devi, Pappu Devi, Mumal, Radha Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar
n Kanwar, Khama Devi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu
atu Devi, Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi, Kisturi, Noja
i, Ganwara Devi, Ganga Devi, Devi, Barju Devi, Reshami, Samu Devi, Nenu Devi, Pappu
ashi Devi, Jamana Devi, Nathi Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan Kanwar,
amala Devi, Rami Devi, Vidha Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Khatu Devi,
gani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi, Ganwara
mal, Radha Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar Devi, Kailashi Devi,
evi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu, Mukhi Devi, SanKisturi, Noja Devi, Sugani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi,
Devi, Pappu Devi, Mumal, Radha Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar
n Kanwar, Khama Devi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu
atu Devi, Shakari Devi, Jawara Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi, Kisturi, Noja
i, Ganwara Devi, Ganga Devi, Devi, Barju Devi, Reshami, Samu Devi, Nenu Devi, Pappu
ashi Devi, Jamana Devi, Nathi Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan Kanwar,
amala Devi, Rami Devi, Vidha Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Khatu Devi,
gani Devi, Chothi Devi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi, Ganwara
mal, Radha Devi, Sua Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar Devi, Kailashi Devi,
vi, Mohini, Maghi Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu Devi, Kamala Devi,
evi, Jawara Devi, Tijan, Laxmi, Shanti Devi, Dhapu Devi, Kisturi, Noja Devi, Sugani Devi,
nga Devi, Devi, Barju Devi, Reshami, Samu Devi, Nenu Devi, Pappu Devi, Mumal, Radha
i, Nathi Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan Kanwar, Khama Devi, Mohini,
i, Vidha Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Khatu Devi, Shakari Devi, Jawara
evi, Kishani, Lala Devi, Badu Devi, Premi Devi, Hurma Devi, Ganwara Devi, Ganga Devi,
a Devi, Chuni Devi, Jamana Devi, Nasiba, Shayar Devi, Kailashi Devi, Jamana Devi, Nathi
Kanwar, Phuli Devi, Jyani Devi, Chhini Devi, Nenu, Pappu Devi, Mumal, Radha Devi, Sua
Devi, Laxmi Devi, Gomati, Ganwara Devi, Shohan Kanwar, Khama Devi, Mohini, Maghi
Kanwar, Muli Devi, Mukhi Devi, Santosh Devi, Khatu Devi, Shakari Devi, Jawara Devi, Tini, Lala Devi, Badu Devi, Premi Devi, Hurma Devi, Ganwara Devi, Ganga Devi, Devi, Barju
ni Devi, Jamana Devi, Nasiba, Shayar Devi, Kailashi Devi, Jamana Devi, Nathi Devi, Laxmi

Carriers of change
The CHWs played a vital role in
changing the societal make up
of their communities. They organised their communities and
educated them on bettering the
living, motivating them to take
the ownership of health, education and livelihoods. The women have removed their social veils
and made space for themselves
and other women in the society.
The anecdotes of the women and
the Urmul team draws from the
various experiences and elucidated the changes they brought
to their own lives. The women
drove the change by setting an
example themselves for others to
watch, learn and replicate.

Urmul Seemant